How could the health care issue have turned from a reform that was going to make Barack Obama ten feet tall into a poison pill for Democratic senators? Whether or not Martha Coakley squeaks through in Massachusetts on Tuesday, the health bill has already done incalculable political damage and will likely do more. Polls show that the public now opposes it by margins averaging ten to fifteen points, and widening. It is hard to know which will be the worse political defeat -- losing the bill and looking weak, or passing it and leaving it as a piñata for Republicans to attack between now and November.

The measure is so unpopular that Republican State Senator Scott Brown has built his entire surge against Coakley around his promise to be the 41st senator to block the bill -- this in Ted Kennedy's Massachusetts. He must be pretty confident that the bill has become politically radioactive, and he's right.

It has already brought down Senator Byron Dorgan of North Dakota, a fighter for health care and other reforms far more progressive than President Obama's. Dorgan championed Americans' right to re-import cheaper prescription drugs from Canada, a popular provision that the White House blocked. Dorgan, who is one of the Senate's great populists, began the year more than twenty points ahead in the polls of his most likely challenger, North Dakota Governor John Hoeven. By the time he decided to call it a day, Dorgan was running more than twenty points behind. The difference was the health bill, which North Dakotans oppose by nearly two to one. The fact that Dorgan's own views were much better than the Administration's cut little ice. He was fatally associated with an unpopular bill.

So, how did Democrats get saddled with this bill? Begin with Rahm Emanuel. The White House chief of staff, who was once Bill Clinton's political director, drew three lessons from the defeat of Clinton-care. All three were wrong. First, get it done early (Clinton's task force had dithered.) Second, leave the details to Congress (Clinton had presented Congress with a fully-baked cake.) Third, don't get on the wrong side of the insurance and drug industries (The insurers' fictitious couple, Harry and Louise, had cleaned Clinton's clock.)

But as I wrote in Obama's Challenge, in August 2008, it would be a huge mistake to try to get health care done right out of the box. Obama first needed to get his sea-legs, and focus like a laser on economic recovery. If he got the economy back on track, he would then have earned the chops to undertake more difficult structural reforms like health care.

Deferring to the House and Senate was fine up to a point, but this was an issue where the president needed to lead as only presidents can -- in order to frame the debate and define the stakes.

Cutting a deal with the insurers and drug companies, who are not exactly candidates to win popularity contests, associated Obama with profoundly resented interest groups. This was exactly the wrong framing. This battle should have been the president and the people versus the interests. Instead more and more voters concluded that it was the president and the interests versus the people.

As policy, the interest-group strategy made it impossible to put on the table more fundamental and popular reforms, such as using Federal bargaining power to negotiate cheaper drug prices, or having a true public option like Medicare-for-all. Instead, a bill that served the drug and insurance industries was almost guaranteed to have unpopular core elements.

The politics got horribly muddled. By embracing a deal that required the government to come up with a trillion dollars of subsidy for the insurance industry, Obama was forced to pursue policies that were justifiably unpopular -- such as taxing premiums of people with decent insurance; or compelling people to buy policies that they often couldn't afford, or diverting money from Medicare. He managed to scare silly the single most satisfied clientele of our one island of efficient single-payer health insurance -- senior citizens -- and to alienate one of his most loyal constituencies, trade unionists.

The bill helped about two-thirds of America's uninsured, but did almost nothing for the 85 percent of Americans with insurance that is becoming more costly and unreliable by the day -- except frighten them into believing that what little they have is at increased risk of being taken away.

All of this made things easier for the right, and left people to take seriously even preposterous allegations such as the nonsense about death panels. It got so ass-backwards that the other day Ben Nelson, who successfully held out for anti-abortion language and a sweetheart deal for Nebraska's Medicaid as the price of his vote, found himself facing a wholesale voter backlash.

Nelson began running TV spots assuring Nebraska voters that the Obama health plan is "not run by the government." That's one hell of a slogan for a party that relies on democratically elected government to offset the insecurity, inequality and insanity generated by private commercial forces. If not-run-by-government is the Democrats' credo, why bother?

So we went from a politics in which government is necessary to provide secure health insurance -- because the private insurance industry skims off outrageous middlemen fees and discriminates against sick people -- to a politics in which Democrats, as a matter of survival, feel they have to apologize for government. Thank you, Rahm Emanuel.

The budget-obsessives around Obama also insisted that most of the bill not take effect until 2013, so that all of the scary stuff gets three years to fester before most people see any benefit. Call it political malpractice.

Finally, the health insurance battle sucked out all the oxygen. When Obama made time to work the phones personally, it wasn't to enact serious financial reform (this was left to the tender mercies of Tim Geithner) or to fight for a real jobs program (deficit hawks Peter Orszag and Larry Summers got to blunt that one). No -- Obama got on the phone and met with legislators to round up the last vote or two for a sketchy health reform that crowded out far more urgent issues.

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